長期照顧需要已被視為重大社會風險，台灣以在地老化為總目標，將長期照顧納入社會保障體系的一環，為了實踐在地老化並降低醫療與長期照護成本， 以居家社區為基礎的長期照護服務整合模式，受到國際重視與推廣，透過整合型服務以全面回應家庭的長期照顧需求，更顯其重要性。伯拉罕共生照顧合作社在台中和平區展開以居家/社區為基礎的在地整體照顧體系，以全人全家型理念，執行 all in one 全效合一型服務來回應需求。本文介紹（1）重症返家、（2） 24 小時服務以及（3）原住民就業等三個案例，來帶領讀者體會實務場域中 all in one 服務運作的七大面向（20 項核心元素），包括：整合照護、公私共聘、全時服務、居服共案、專業與產能、多元場域、資源連結展現多元服務。

Long-term care unmet need is regarded as a significant social risk. With aging- in-place as the goal, Taiwan incorporates long-term care into its social protection system. To achieve aging-in-place while reducing the costs of providing medical and long-term care, the Home- and Community-Based Integrated Care system is emphasized and advocated by the international community. The system's ability to respond to families' various needs through integrated services further demonstrates the importance of the system. Plahan is a home and community based integrated care system in Heping District, Taichung. Plahan adopts the whole-person, whole-family concept to implement all in one services to respond the needs. This paper uses the following 3 examples： (1)Home care for critically ill patient； (2)24 hours service；(3) Providing employment for indigenous community to show the seven dimensions (20 core elements) of all in one services including: integrated care, public and private co-employment, 24 hours service, home-helper team work, profession and productivity, multiple fields and resources linkage to implement multiple services.

長期照顧; 以居家/社區為基礎的整合照護; 全效合一服務; 伯拉罕

Long-Term Care; Home- And Community-Based Integrated Care; All In One Services; Plahan